Obesity in the younger age groups is becoming an ever-growing problem that manifests its outcomes through adulthood. Laparoscopic sleeve gastrectomy is a bariatric procedure that has proven to be effective for the long-term management of obesity in adults (11–14). However, long term data on adolescents is currently lacking. One of the main reasons behind this finding is because bariatric procedures, until recently, have been limited to adults (15). Therefore, we chose to investigate the long-term outcomes of this procedure in adolescents. Our paper was able to prove sustained weight loss over a 10 year follow up period with good outcomes in regards to comorbidity resolution. Furthermore, there were minimal negative outcomes encountered in our cohort over the ten year period, with 12% of our population developing GERD and/or gall bladder stones 5 years post-operatively.
Worldwide in the year 2016, obesity amongst children was estimated to be present in around 60 million of the population (16). Further, according to the World Health Organization, the prevalence of obesity and overweight in that age-group increased from 17–21% between the years of 2007 and 2019 respectively (17). In Kuwait alone obesity was recorded at a record high rate of 33% amongst adolescent age groups in 2019 (18). Therefore, the management of this disease has become imperative to prevent lifelong sequala in this population. Recent reports have been able to prove that laparoscopic bariatric procedures in the adolescents is not only safe, but demonstrate incredibly successful results in terms of weight loss and comorbidity resolution (19–21).
It is important to bear in mind that outcomes to laparoscopic sleeve gastrectomy’s are influenced by many factors such as adherence to the post-operative regimen, lifestyle, diet, and follow up appointments. Nonetheless, we were able to show a decline in post-operative BMI from 47.8 kg/m2 to 31.3 kg/m2 12 months post-SG. This was in line with results obtained in older patients undergoing SG in our hospital (22). The study also proved that the vast majority of our population were able to maintain their BMI even after a 10 + year follow-up period. These weight loss results were further paralleled regionally in studies from Qatar as well as the United States (23, 24). In a similar pattern the %EWL followed the BMI changes as such that after 12 months from the procedure, approximately 77.03% EWL was achieved, which was maintained 13 years post-operatively. This provides insight on the long-term effectiveness of bariatric surgeries such as the one conducted in our research (4).
SG is a helpful tool that aids in weight loss which can help with the metabolic manifestations associated with obesity. It has been proven to lower the undesirable complications such as hypertension, diabetes, and hypercholesterolemia (4, 23). However, these outcomes were not fully assessed in our study mainly because the majority of our study participants did not suffer from the complications to begin with. However, the 2 patients that presented with hypertension pre-operatively did not demonstrate resolution of their hypertension 10 years post-op. A possible explanation for the lack of complete hypertension resolution might be related to other factors, such as low vitamin D levels, which were not assessed in our patients. A previous study observing the effect of hypovitaminosis D on the resolution of hypertension among patients undergoing Roux-en-Y Gastric Bypass (RYGB) interestingly found that vitamin D reduction was significantly associated with a lack of resolution of HTN compared to those with adequate levels (42 vs 61%; p = .008) (25).
Since bariatric surgery such as SG is known to cause rapid weight loss and hence, increase the development of gall stones (26), it was witnessed in our study that approximately 20 of the participants (12.1%) developed gall bladder stones at around 4 years post-op. This has been seen to be a common finding in post-bariatric surgery patients as shown by previous studies (27–29). Further, females have been proven to be at a greater risk of developing cholelithiasis, with a female to male ratio of 2.1:1 (30), and given that the majority of our patients, as well as patients undergoing bariatric procedures, are female (71.1% of our cohort), this high rate of gallstone formation is not surprising. When it came to looking at other morbidities encountered post-operatively, 21 (12.7%) patients developed GERD approximately 5 years later, while a leak was encountered in 1.2% of the patient. This rate is lower than that of the average leak rate encountered post primary SG which is approximately 2.2% (31).
Adolescents have been shown to have a higher risk of follow-up interruption than adults, mainly due to their more mobile lifestyle at that age (university, employment or personal life changes). This phenomenon can be witnessed in our study by the fact that 87 (53%), 112 (68%) and 132 (80%) patients that were eligible for evaluation at 6 months, 1 year and 10 years after SG were lost to follow-up, respectively. Therefore, emphasis on adherence to the post-operative medical treatment and team is an essential key for the successful treatment post-bariatric surgery in pediatric and adolescent patients (32).
Our study presents with several limitations that should be highlighted. Firstly, our study is one that it is a retrospective case series without the presence of a control group. However, it is one of the fewest published in this region with a long follow-up period targeting the adolescent age group in a geographic location which is heavily burdened by obesity. Second, even though this is one of the largest single-series studies conducted on this population of bariatric patients, the total number of patients is still small. Thirdly, the number of patients followed up decreased significantly over the follow-up period, which is an issue seen in adolescent patients, and therefore decreases the strength of the long-term evaluation post-SG.